Vascular Disorders PDF

VASCULAR DISORDERS INTRODUCTION: Hypertension:- Hypertension (HTN) is a chronic disease that can last for years or life long. Untreated HTN can lead to serious health Conditions, such as damages to vital organs like kidney , heart, brain and the eyes. DEFINITION: HTN is a term used to describe high...

VASCULAR DISORDERS INTRODUCTION: Hypertension:- Hypertension (HTN) is a chronic disease that can last for years or life long. Untreated HTN can lead to serious health Conditions, such as damages to vital organs like kidney , heart, brain and the eyes. DEFINITION: HTN is a term used to describe high blood pressure a condition where there’s repeatedly sustained elevation in arterial BP. This implies that the blood pressure remains high when checked severally at the same period of the day eg morning hours. INCIDENCE: HTN affects approximately 75 million adults in the US and more than 1.5 million adults in Nigeria annually. Incidence increases with age, more in male (33%) than in women (27%) until the age of 55. CLASSIFICATION HTN has several classifications Among different schools of thought. Some classes include; 1) Into 4 classes, stages of normal, mild, moderate and severe NORMAL BP: The normal range for blood pressure is between, less than 120 mmHg and less than 80 mmHg. MILD OF PRE-HYPERTENSIVE STAGE: BP measures of 120-139mmHg Systolic and 80-89mmHg diastolic pressures. MODERATE OR STAGE 1 HBP; BP measures of 140-159mmHg systolic and 90-99mmHg diastolic pressures SEVERE OR STAGE II HBP: BP measures of 160mmHg and above and diastolic pressure of 100 mmHg or abole TABULAR REPRESENTATION OF CLASSES /STAGES OF HTN CATEGORY SYSTOLIC mmHg DIASTOLIC (mmHg) Normal BP =100 2) Into two categories of primary (1°) and secondary (2°) a)1° or essential HTN : This type accounts for 90-95%of cases. Most adults with HBP fall into this category, cause is unknown but it is thought to be a combination of generics, diet, life style, age. It has no definite Preventive measure. b) 2° or non-essential HTN - This accounts for 5-10% of cases. It is a Condition with Identifiable and potentially reversible cause, mostly In younger persons aged 18-40 Causes Include narrowing of renal arteries, adrenal glands disease, side effects of some medications, such as contraceptive pills, Stimulants, antidepressants, Over-the-counter drugs, thyroid abnormalities , coarctation of the aorta and pregnancy. 3. Other classification that Constitute abt 10 to of Cases lnclude: ~ Resistant HTN: This is a type of HBP that is difficult to control. It requires multiple medications, a combination of 3 or more anti hypertensives to manage Hypertensive Crisis: This is a broad term for two hypertensive Conditions. HTN urgency and HTN emergency. The two conditions Occur when Bp becomes very high, Possibly Causing Organ damage. Hypertensive urgency occurs when Bp spikes up to 180/110mmHg but there is no Organ damage occured. BP can be brought down Safely within hours with antihypertensive medications. Hypertensive emergency also known as malignant hypertensión; Occurs when Bp is so high that Organ damage can occur (BP is often as high as 250/150 mmHg). It is characterised by severe headache, nausea, vomiting, visual disturbances, drowsiness, chest pain, shortress of breath. It is a medical emergency. Pt is nursed ln lntensive care unit to reduce rate of Organ damage. The management consist of the administration of Intravenous Hydralaxin (apresotin), and frusemide (diuretic) Organ damage associated with HE lnclude, Changes in mental status eg Confusion, stroke, heart failure, Angina pectoralis, Pulmonary Oedema, heart attack, aortic anureysm, Eclampsia (in pregnancy ) ~Isolated Systolic HTN: A Bp with Systolic pressure above 140mmHg and diastolic pressure below 90mmHg. It is mostly seen Older Person 6o yrs and above. PATHOPHYSIOLOGY Two conditions result in the rise of arterial pressure, cardiac output (CO) and peripheral resistance(PR). If PR Increases a greater force (pressure) is required to pump blood throughout the body. This sustained increase in Bp causes vascular changes such as thickening (Sclerosis), thus resulting to reduced blood supply to the tissues and ultimately reduced functional ability(the arterial wall thickness causes narrowing of their lumen) thrombosis may likely Occur. This arterial wall may develop necrotic areas that may weaken or rupture under High Pressure Causing epistaxis, bleeding of the retina and apoplexy. The four Organs that are most frequently targeted for damage are the heart, the kidneys, the brain, and eyes. This Sustained increase in arterial pressure also increases the work load of the heart, the myocardium may hypertrophy and eventually some pumping factuce develop as the pressure Persists. The sclerosis of the coronary arteries may result In Ischemic heart disease, angina pectoric or myocardial infarction. Oedema occurs due to Impaired kidney function because of sclerosis, haemorrhage or thrombosis of the renal arteries. There is degenerative changes in the eyes and mental involvement manifesting in headache and fatigue because of Impaired blood supply to the brain. CLINICAL MANIFESTATIONS (S/S) Asymptomatic Symptoms manifest in moderate to severe cases. -Headache, usually in the Occipital region frequently in the morning hours, Headache may be a feeling of stiffness or tightness -Dizziness/droosiness -Fatigue - Blurring of vision visual disturbances. -Epistaxis -Palpitation -Dyspnoea -Vertigo - Angina pectoris - Light headedness - Sustained high -Syncope(fainting) -Insomnia -Tinitus DIAGNOSTICS PROCEDURES History/physical exam Routine urinalysis Bun and serum creatinine test (to screen retinal involvement) Serum electrolyte and uric acid (ascertaining serum electrolytes especially potassium levels, this is very important in detecting aldosteronism, uric acid levels are determined to establish baseline since the level often rises with diuretic therapy) Blood glucose levels (this assists in identifying endocrine causes such as DM and Cushing) Complete blood count ((BC) Serum lipid Profile- cholesterone and triglycerides, their levels may Indicate risk factors that predispose to atherogenesis Chest x-ray: Provides baseline regarding heart size as well as aortic dilation and rib notching which occurs with coarctation of the aorta. ECG, Provides baseline information regarding the cardiac status, and for prevention and treatment (RX). TREATMENT AND MANAGEMENT Objectives of treatment/mgt of HBP includes preventing and lessening complications. In 2° HTN, the mgt is directed towards Correcting the many precipitating Conditions. In 1° treatment isdirected at lowering the Bp in order to reduce demand on the CVS. Chemotherapy Drug mgt in HTN include the use of 1) Diuretics which Include; a. thiazides, eg hydrochlorothiazides b. Loops, eg frusemides. c. Potassium sparing agents eg spironolactone/ aldactone 2) Angiostesin converting enzyme (ACEs) inhibitor, ey Captepril, Enalapril, Potassium supplements. 3) Vasodilators, eg Hydralazine, ACEs inhibitor etc 4) Drugs that act on the CNS a. Centrally acting eg methyldopa b. Post ganglionic blockers, eg hexamethonium c. Alpha blockers eg prazosin d. Beta (B) blockers eg, propranolol 5) Calcium channel blockers, eg Nifidipine Nursing MGT A) Observation: Careful monitoring of Bp at prevalent intervals. Bp assement is needed to determine the effectiveness of medications therapy and detect any change that Indicates need for change in treatment plan. A Complete history is Obtained to access signs and symptoms that indicate target Organ damage. Specific attention should be paid to the rate, rhythm and character of Pulse, to detect effects of HTN on the heart and blood vessels B) Diet: Discuss with patient and family the need to achieve and maintain a normal body weight as this may facilitate lowering of Bp Reduction of salt intake is recommended as excess sodium expands intravascular volume ( Na increases H2O reabsorption and increases blood volume thereby increasing Bp ) Reduction in alcohol intake is recommended as alcohol increases the risk of obesity C) Exercise Regular physical activities is beneficial to achieve and maintain a Satisfactory weight. plan for regular exercise is done once HTN is under Control D) Rest The relationship between stress and HTN has not been clearly stated but it is generally believed that stress prediposes one to HTN and therefore increased its complication. Both physical and mental rest should be advocated to Conserve energy and avoid undue stimulation (excitation) of the sympathetic Nervous system Encourage pt to express feelings of Stress and identify stressors in the environment. Teach patient relaxation techniques that can be used to reduce stress in a variety of settings, such as- ī. soothing music -listening to a soothing (or antigenic) music īī. Excercise like walking , Pacing, yoga etc ĪĪĪ. Laugh out loud, this lowers cortisols (body's stress hormones) and boosts endophins (brain chemicals that help with mood) ĪV. Deep breathing exercises, also boosts endorphins V. Meditating (on God's words), gratefulness, being grateful to God for your blessings, Channels out negative thoughts and worries , also grateful to people who has impacted your life. VI. Keep gratitude jotters, abt three (One by your bed side, One by your purse and one at work place) to help you remember all the things that are good In your life, Count your blessings. Use these jotters to save good experiences, like a child’s smile, a sunshine filled day and good heatth. Don't forget to celebrate accomplishments eg mastering a new task at work, passing exams, learning a new hobby etc. E) Elimination Straining on defaecation can raise the Bp and cause rupture or damage blood vessels, therefore constipation should be avoided. F) Health Education and prevention a) Educate pt and family on the importance of life-style change and adherence to healthful behaviours b) Routine Screening should be done to identify individuals with potential hypertensive heath problems. c) Great emphasis should be placed on stopping Smoking, excesive alcohol consumption PREVENTION HTN is usually called the "Silent killer" because about 67 % of person's with HBP are unaware, therefore regular check of Bp Is recommended. American heart Association (AHA) recommends that adults should Check their Bp at frequent intervals at routine health visit and more frequently at home or in the community, even when Bp. is normal CEREBROVASCULAR ACCIDENT (CVA) OR STROKE CVA is an abrupt Or rapid onset of a neurological deficit resulting from a disease of the blood vessels Supplying the brain and Consequent Interruption of blood supply to the brain. The part of the brain damaged by loss of blood supply can no longer perform their Specific, Cognitive , sensory or motor, as well as emotional functions. The resulting impatience can be slight or severe, and temporary or permanent. INCIDENCE CVA is a leading cause of death and permanent disabilities, with the highest incidence In people after 60 years of age, higher In mates, more Common in blacks than in the whites. CAUSES Atherosclerosis Cerebral thrombosis Cerebral embolism aneurysms trauma ste PREDISPOSING FACTORS HTN, DM, Cardiovascular disorders (CVDs) blood lipids abnormalities and certain lifestyles eg (cigarette smoking, alcohol, Obesity, high blood cholesterone. TYPES There are two main types:- Ischaemic & Haemorrhagic stroke. Ischaemic stroke: This is the most common type (abt 80-85%) a medical emergency. It results from a decrease blood flow to the brain due to partial or complete occlusion of an artery. The most common cause is cerebral thrombosis and embolism. Haemorrhagic Stroke: Thus occurs as a result of spontaneous bleeding in the brain tissue itself or into subarachnoid Space. It accounts for about15% of CVA. Most (about 80%) of haemorrhagic stroke results from spontaneous rupture of small blood vessels caused by uncontrolled HTN, while the remaining 20% is associated to arteriosclerosis, venous malformations, intracranial aneurysm or certain medications eg anticoagulants. Other less common type of CVA are transients ischemic stroke and cryptogenic stroke. Transient Ischemic Stroke(TIA): This is a brief episode of neurological dysfunction caused by loss of blood for to the brain, spinal cord or retina of the eyes, without tissue death (infarction m). TIA, have the same underlying mechanism as Ischemic stroke, It may be a warning sign of a future severe stroke. It lasts from a few minutes to abt 24 hrs. Warning signs Include weakness, numbness or paralysis on one side of the body, trouble with seeing, slurred speech and severe headache no apparent cause. About one-third of people who experience TIA may Progress to serious stroke within one year, However, It's prognoses is good, aut (91%). it does not cause Permanent tissue damage, If prompt mgt is initiated. Other terms used to address TIA include mini stroke and partial stroke. Cryptogenic stroke is a stroke of unknown origin. PATHOPHYSIOLOGY OF CVA(Stroke) Any cause of CVA can partially or completely reduce blood flow to the Cerebral tissue this decreases oxygenation to the area of the brain Supplied by the involved blood vessels causing Ischaemia (Cerebral infarction). If the brain experiences anoxia for more than 10 mins, Irreversible brain damage may occur, large areas of infarction usually results in severe disability or death. when cerebral blood supply is thus affected, there is temporary or permanent loss of neurological functions. If an artery ruptures, normal brain metabolism is disrupted by the brain being exposed to blood and by increased intracranial pressure which further compresses the brain tissue. The signs and symptoms of CVA are varied and depended on the part of brain Involved, size of the area involved and colateral blood flow.  The major manifestations include, altered movements, loss of sensation  Sudden Severe headache.  Numbness or weakness of the face, arm or legs ,esp on one side of the body  Altered Consciousness.  Motor deficit Include: Hemiparesis, hemiplegia, facial drop, ataxia, Paresthesia.  Speech deficits Aphaxia, dysarthria.  Sensory disturbances, cognitive disability, Perceptual disturbances, Short and long term memory loss, decrease attention span, Impaired ability to Concentrate, poor abstract reasoning, altered Judgement.  Emotional deficits, Loss of self control, emotional disability. DIAGNOSTIC PROCEDURES - Physical exam/heath history -Neurological exam eg test of vision(eye movement), speech. - Computerized tomography (CT) scan, this may be the primary diagnosing procedure used after a stroke to determine if is a haemorrhagic or ischaemic stroke. -Computerized tomography Angiography(CTA) scan; this can used In place of CT scan -Magnetic Resonance Imaging (MRI) -Echocardiography -Anteriography MANAGEMENT AND TREATMENT Mgt is collaborative Comprising Cardiologist, Vascular Surgeons and Neurologists etc. Chemotherapy: when the cerebral oedema accompanying a stroke threatens to brain herniation, a dehydrating agent is used. IV manitol is the drug of choice. It is an hyperosmotic agent which reduces the Intracranial pressure (ICP) caused by the oedema Corticosteroids, eg Dexamethasone also very useful, it acts as anti-inflammatory agent to break the cycle of Increasing oedema by reducing inflammation. Anti-Coagulants,Platelets aggregation Inhibitors and statin. -Anti-Coagulant, eg Heparin, Warfarin, apixaban etc to prevent blond clots(thrombosis) formation. Their major side effects are: Indigestion and bleeding risks. -Platelets aggregation Inhibitors eg aspirin Clopidogrel they work by reducing the ability of platelets to stick together to form blood clots. -Statins, eg atorvastatin, Simvastatin, Rosuvastatin. they reduce level of cholesterone in the blood, by blocking an enzyme in the liver that produce cholesterone Anti-hypertensive medications and cardiac monitoring. Surgical mgt: this is mostly carried out in the treatment of TIA , the surgery Perfomed is known as carotid endarterectomy Nursing mgt: To reduce the incidence of stroke, the nurse needs to direct efforts towards stroke Prevention for those at risk pts. Incidence of Stroke has reduced with the use of aspirin. Clients with known risk factors, such as, Dm or cardiac dysfunction, should be monitored closely I．OBSERVATION- Observe Vital signs regularly, assess for airway potency, assess and monitor neurological Status, assess for any precipitating event or a decreasing level of Consciousness and report Promptly. If there is respiratory distress, administer O2. 2. POSITIONING- place patient on lateral position, but time spent on the affected side should be minimised if sensation is impaired. Change pt's Positien every 2 hours and treat the pressure aress every 4 hrs. A small pillow is placed in btw the legs and under the pelvis and arm, to relieve pressure and maintain Good alignment pt's head should be slightly elevated to decrease icp 3. EXERCISE: Passive exercise is commenced on the affected extremity. The extremities are put through a full range of motion 4 or 5 times a day to maintain mobility, region motor control, Prevent contractions in the paralysed extremity, prevent further deterioration of the neuromuscular System and enhance Circulation. The pt is expected and encourage to exercise the unaffected side, at least 5 times daily for 10 mins at a time. Early ambulation is initiated as soon as possible, patient is assisted out of bed in graduated way. first patient is taught to maintain balance while sitting then he is taught to balance while standing The training period for ambulation should be short and frequent. As pt Gains strength and confidence, an adjustable care can be used to support him/her  4. SELF CARE: As soon as the pt can sit up, personal hygiene activities are encouraged, such as brushing of teeth, shaving, bathing & eating 5. DIET: Intially tube feeding is advocated to reduce/prevent the risk of aspiration. Accurate Intake and Output record should be kept. 6. ELIMINATION: Incase of Incontinence, pt is catheterised, If there is Constipation, a high fibre diet and adequate fluid (abt 2 to 3 litres dly) Should be provided and a regular time established for toileting. 7. HEALTH EDUCATION: family members play Important role in the pt recovery by Counseling and support system should be made available to them, Provide pt with care on thing that significantly affect their health andInterfere with their life. If pt is alert, explain these and reasons for follow up. 8. REST: The ot is kept on bed rest. If pt is unable to rest, mild sedative may be given with caution. Pt should be kept warm & quiet. Bed side rails are used if the pt is disorientated/ restless and uncooperative. 9. DISCHARGE PLAN: The home care provider needs instruction on those Practices necessary to contious at home, such as, exercise and ambulation technique, dietary requirements, recognition of signs indicating possibility of another episode of stroke such as headache, vertigo, numbness and visual dimubances. *Medication regimen, time, place and frequency of follow ups, activities such as occupation, therapy and psychosocial therapy. Complications: pneumonia (mainly aspiration pneumonia), immobility, vasospasm , seizures etc ARTERIOSCLEROSIS/ATHEROSCLEROSIS ARTERIOSCLEROSIS: the most common disease of the arteries. It is a diffuse Process whereby the muscle fibres and endothelia lining of the walls of the arteries and the arterioles, the hardening of the arterial walls that results in its loss of elasticity. ATHEROSCLEROSIS: This is a from of arteriosclerosis in which arterial walls hardening is due to deposit of fats and Fibrin. It is a chronic degenerative process caused by a building plaque that narrows the blood vessels and reduce or blocks oxygen and nutrients from reaching their target Organs. Although, the Pathologic process of arteriosclerosis and atherosclerosis differ, One hardly occurs without the other. The mayor difference to the two conditions that are often used interchargebly is that arteriosclerosis mainly affects the small arteries and arterioles that Supply O2 and food nutrients to the body cells, while atherosclerosis affects large and medium sized arteries. Again, atherosclerosis is just a type of arteriosclerosis that affects arteries of the extremities, mainly in the elderly.